Welcome to my blog. HIV prevalence is not a reliable indicator of sexual behavior because the virus is also transmitted through unsafe healthcare, unsafe cosmetic practices and various traditional practices. This is why many HIV interventions, most of which concentrate entirely on sexual behavior, have been so unsuccessful.

Wednesday, May 30, 2012

I am in sympathy with the popular notion that people in developing countries need access to information, especially about health and other matters that profoundly affect their lives. But I wonder how people are to filter out the noise and only act on the information that really is to their benefit. How are people to know the difference between truth and lies, usage guidance and sales pitch, campaigns to promote health and campaigns to fulfill the sordid aims of some overfunded eugenicist (for example) or a power crazed imperialist? You could spend a lifetime doing some of these.

Take for example the CIA's fake polio vaccination drive to get Osama Bin Laden's DNA: clearly this had nothing at all to do with health, but was related to the aims of the very people who trained and supported Bin Laden for a long time. But how can anyone tell? Organizations that started out as overtly eugenicist later became covert eugenicists and many of them went on to be some of the biggest recipients, first of 'reproductive health' funding, at least some of which consisted of aggressively marketing various birth control methods, then of HIV 'prevention' funding, some of which consisted of, well, pretty much the same thing.

Even comfortably off, well educated people in Western countries seem to be confused. Dubious arguments about circumcision reducing men's risk of being infected with HIV through heterosexual intercourse are understood as also meaning that women are partially protected, even though research has shown that it actually increases the risk to women. Arguments for mass male circumcision campaigns for sexually active adults, who may possibly be able to give their consent if given correct information (which is unlikely to happen), are used for infant circumcision. But infants tend not to engage in heterosexual sex and are unlikely to do so for many years. As adults they may be able to give their consent to the operation, though possibly with as little likelihood of that consent being informed as it was for their parents.

Apparently some bright spark has introduced 'moonlight circumcision' on the border between Kenya and Uganda. Voluntary Counselling and Testing clinics have been providing moonlight services for some time but they tend to attract a lot of people who have had a few drinks first. The notion of pressganging comes readily to mind. The excuse is that it's for people who have to work during the day. One of the 'mobilizers' is quoted as saying "It's encouraging to note that chiefs, their assistants and church priests have also presented themselves, albeit secretly". Are the priests so misinformed that they think they can have risk free unprotected sex once they are circumcised? Or do they think they are at risk even though they are celibate?

The mobilizer also "urged the youth to remain faithful to one partner, use a condom, abstain from sex and know their HIV status", which suggests that he is not very familiar with the published literature that claims circumcision reduces the risk of being infected with HIV: firstly, the literature assumes, as the mobilizer does, that all HIV transmission is sexual; secondly, that the level of protection is high when it is actually very low (1.3% absolute risk reduction); thirdly, the research also found that correct penile hygiene gives far better protection than circumcision, etc, you get the point.

Much of what is dressed up as health promotion is really just some kind of propaganda, from those who believe population control is the key to development, those who want to sell pharmaceutical products that they find difficult to shift back home (injectable Depo Provera), those who recognize the damage that genetically modified organisms can do, but also the profits that can be amassed, and those who really don't give a damn about the ill-effects of their programs (Tuskegee, mass male circumcision) as long as they get to satisfy their own needs, however pathological.

Clearly, getting information out is not the only problem. I met people in Kenya who had heard all about agricultural products that cost very little and are guaranteed to give high yields every year, no matter what the prevailing conditions are, all from someone working from a company called Syngenta. It clearly matters who is providing the information, or even access to it, why they are doing so and what ulterior motives they may have. Not that it's always wrong for them to have ulterior motives, but it's hard to evaluate the information without knowing such things.

So it remains to be seen whether access to information campaigns will result in a free-for-all of 'providers' hawking their infomercials dressed up as training courses, free samples designed to get people hooked on things they don't need and can't afford, evangelists selling salvation, or worse, get rich quick schemes, technocrats, quacks, supremacists, megalomaniacs, pseudo-philanthropists, etc, which is the status quo but with better delivery channels, or something else entirely. What kind of information provision campaign can avoid these pitfalls?

Monday, May 28, 2012

I would like to make some clarifications to yesterday's blog after receiving comments on Twitter. I am not opposed to the use of vaccines, especially for diseases like polio. But there are too many diseases to line up vaccines, one by one, for each remaining disease. And all the time vaccine programs are going on, people are drinking contaminated water, sewage is being dumped in the water supply, nutrition levels are low, etc. Vertical health programs, tackling one disease at a time, is not the best way of approaching deadly diseases. And health is not just an array of diseases to be 'fought' with various different pharmaceutical products. Think of it this way; we don't have cures for many diseases but we do know that where living conditions are terrible, disease burden will be high.

Gates is in favor of vertical programs and is using the example of polio vaccination, which has been going on for decades, slowly eradicating the disease in one country after another, to push for the same approach to other diseases. Some of these other diseases might better be addressed by spending more on provision of clean water and sanitation or nutrition or a combination of measures. But his aim is to spread technology (drugs, GMOs, geoengineering, birth control, etc), not to ensure high levels of health. The amount of time, money and effort spent on polio eradication is worthwhile; but if the same amount of time, money and effort were spent on water and sanitation, the need to spend time on vaccinations for each serious water-borne disease would be reduced considerably.

The authors briefly raise the issue of intense competition being involved in such programs, which can strongly influence critical analysis; also the "conflation in medical journals of fine-grained and detailed scholarly research (undertaken mainly by parasitologists and epidemiologists) with broad assertions that are best understood as advocacy statements", an example of which may be found in a recent post on this blog (though much of the conflating was done by the lead author of the article); and the authors call for insights from social scientists not to be dismissed, as they so often are. They feel that current efforts will not be sustainable and will not 'make poverty history', as the popular slogan has it.

Gates and others seem to take a kind of scorched earth approach to health and development, as if money and technology are weapons. But what is worse, they seem to think of people suffering from diseases, or at risk of those diseases, as the enemy, to have various techniques and technologies shoved down their throat (or elsewhere), whether they like it or not. The latent contempt and violence behind mass male circumcision and the highly aggressive marketing of Depo Provera and various birth control methods are obvious enough to some, but other health (and development) programs also need to take into account the recipients, not just those who have decided who the recipients should be.

Sunday, May 27, 2012

Bill Gates' annual letter this year starts by claiming that "innovation is the key to improving the world". But he is quite wrong. It is very basic things that are key to improving the world, health, education, water and sanitation, infrastructure, etc. The sort of innovation Gates is talking about includes vaccines and these are not key to eradicating diseases; they will help, but they will never be enough on their own. Take water related diseases, for example. You can vaccinate everyone against various diseases, one by one, which is how Gates wants to do it, but sickness and premature deaths will continue.

According to Gates, polio has been eradicated in India. But for how long? As long as people are forced to drink contaminated water they will suffer from water related diseases, including polio. Even though it has not infected many people in India for some time it is still in the water and sewage systems. Indeed, throwing more drugs at water related diseases without ensuring that people no longer have to drink their own waste could be contributing to more powerful strains of polio and other diseases that are resistant to any current drugs.

Resistance as a result of overuse of drugs is not a new discovery; it has happened many times before and will continue to happen. Perhaps it is an inevitable consequence of expanding access to drugs. But, as the experience of Uganda shows, there need to be some limits to how drugs are used. Pregnant mothers who are HIV positive need drugs to reduce the chances of transmitting the virus to their babies. But they are best used as a last resort, where the mother was unavoidably infected. It's by no means certain that HVI positive pregnant women are always infected through sexual behavior. Infection through unsafe healthcare can not be ruled out.

But while HIV positive people need ARVs once they have reached a particular stage of disease progression, some would question the increasing use of them for people who will probably remain healthy for years without treatment. And the proposed use of ARVs to 'prevent' HIV already appears to be backfiring in Uganda (sometimes called 'treatment as prevention'), even though it has yet to be officially implemented. Levels of resistance to ARVs there are very high, probably because widespread use of them began several years earlier than in other countries. Resistance means that a lot of people will become sick and many may die. But it also means that the cost of treatment goes up from unaffordable for Africans to astronomical for whoever pays.

As for pre-exposure prophylaxis (PrEP), the use of ARVs to prevent HIV for people who are not infected, there is no telling how widespread resistance may become. To make matters worse, people with resistant strains of HIV can transmit those to HIV negative people. In other words, instead of starting on the relatively cheaper first line ARVs, people who have been infected with a resistant strain need to start with the astronomically priced second line drugs, if they are available and affordable.

The received view of HIV transmission in African countries is that it is almost always transmtted through heterosexual sex and rarely through any non-sexual modes, such as through unsafe healthcare or cosmetic practices. This view is not a result of sustained research, more a result of sustained dismissal of any research that suggests HIV may sometimes be transmitted through the very health facilities that the HIV industry is so keen on people attending. The received view is that it is individual behavior that 'spreads' HIV and individual behavior that needs to be changed by the various finger wagging programs offered to effect this change.

In the same way, we are often told that ARVs fail because people don't adhere properly to the drug regime. Perhaps some don't follow the regime properly; that's certainly the case for most other kinds of drug treatment. But health facilities in African countries are appalling; things go wrong all the time, often without anyone noticing. Increasing the things that can go wrong by prescribing ARVs to all and sundry is asking for trouble. Instead of pointing the finger at individuals for failing to follow a drug regime that may have been impossible to follow to the letter, due to various circumstances, the role that drug use plays in people's health needs to be re-examined, especially in countries where drugs are nowhere near the top of the list of priorities but things like living conditions are.

Gates is deluded. It may be his money that he proposes spending on more and more drugs for Africans, but he is not the one who has to suffer the problems that result from overuse of drugs and underutilization of far more effective development activities, such as provision of clean water and sanitation and the like. If polio just keeps returning, it will be as a result of the sort of health interventions Gates has been advocating for, not despite them. How the man can continue to advocate for a 'decade of vaccines' without considering the conditions people live in is a mystery.

Thursday, May 24, 2012

It's not uncommon to come across articles arguing that funding for HIV is not adversely affecting funding for other health areas and even that funding for HIV is benefiting other health areas. Less common are articles about the basic conditions in the hospitals and health facilities that ordinary people have to use, if they can afford to. While the former articles bear witness to the huge amounts of money being poured into what has become the HIV industry, the latter articles make one wonder what the money is actually being spent on.

In an article entitled "Access to emergency and surgical care in sub-Saharan Africa: the infrastructure gap", Renee Hsia and colleagues go through the sort of data collected by Service Provision Assessment reports from MeasureDHS that should be familiar to readers of this blog. Looking at the six areas of "basic infrastructure, equipment, medicine storage, infection control, education and quality control", the authors show that surgery may be available in many facilities in Ghana, Kenya, Rwanda, Tanzania and Uganda, but it's very unlikely to be safe.

Concentrating on infection control, which is vital for ensuring that healthcare is safe, the authors find that facilities with availability of infection control materials (soap, running water, sharp box, latex gloves and disinfectant) ranged from less than 30% in Rwanda to 0% in Tanzania. In fact, availability was lower than 5% in the other three countries. Appropriate collection and disposal of infectious waste was also low, ranging from less than 80% in Uganda to less than 30% in Ghana.

How willing would you be to be circumcised in any of these countries? Or, what seems like an easier option for some programs when it comes to recruiting, how willing would you be to allow your son to be circumcised? As a woman, would you like to give birth in such facilities? Would you even wish to have an injection, for example, to receive some vaccine or the Depo Provera injectable contraceptive that has been so aggressively promoted in African countries despite carrying a number of health risks?

To be more accurate, it's the PR around Shepard's article that makes a lot of claims that are not borne out by the article. This does not exonerate Shepard and he is cited several times in the PR saying things that do not appear in the article. Interestingly, the article is partly funded by UNAIDS, who should be very happy with this sales pitch. But there's also mention of Abt Associated, who seem to play quite a strong publicity role in an article that appears in a peer reviewed journal. Perhaps they peer reviewed it themselves, you can never be too sure about academic credentials.

Aside from the obvious commercial/financial interests in mass male circumcision programs, injectable hormonal contraception programs and extremely expensive vertical HIV programs, it is far more basic things that ordinary people are most lacking. What could be more basic in a health facility than soap and water, latex gloves, bandages, syringes and the like? But some of the countries receiving hundreds of millions of dollars a year from PEPFAR alone (between 2004 and 2010, Kenya has received almost $2.5 billion, Uganda and Tanzania over $1.5 billion and Rwanda $673 million) can not even guarantee the safety of the simplest medical procedures; many can't even provide these procedures. But it's hardly surprising if a rising tide would fail to float the leaky boats, is it?

According to the leaked cable, a PEPFAR (US President's Emergency Plan for Aids Relief) assessment concludes that "health providers and managers lack the knowledge, supplies, and equipment to protect their patients from acquiring infections such as HIV in the clinical setting", also citing reuse of medical instruments and lack of blood safety. Unsafe medical interventions are said to have resulted in several outbreaks of HIV. 155 children were found to have been infected in Kazakhstan, 110 in Kyrgysztan and over 40 in Uzbekistan.

As a result of all this attention to infection prevention and control there is now said to be a high level of awareness of health facility risks for HIV transmission, although there is little scope for doing anything about it. In stark contrast, several reports into health facility conditions in East African countries have found conditions far worse than those found in Central Asia without this resulting in any investigations into health facility HIV transmission, by CDC, PEPFAR or any other institution. The situations in Central Asia and other areas are well described on the Don't Get Stuck With HIV site, but in East Africa the official line is that 80% of transmission is a result of heterosexual contact and almost 20% is a result of mother to child transmission.

If only USAID or some other body were planning "a situational analysis of primary health care facilities and tuberculosis hospitals in the region, to further identify institutional and systemic barriers to infection prevention" in Eastern and Southern African countries, as they are in Central Asia. After all, HIV rates are higher in sub-Saharan Africa than anywhere else in the world. There's so much to gain from carrying out such an analysis and so much to lose from continuing to ignore health facility transmission of HIV, also called nosocomial transmission.

Central Asian countries are poor, but most African countries are a lot poorer, with fewer medical personnel, lower levels of education, appalling health indicators and crumbling infrastructure. Perhaps nosocomial HIV transmission in African countries is very rare, as UNAIDS, WHO, CDC and others claim. But wouldn't it be a good idea to investigate conditions in African health facilities, as has been done in some countries, especially in areas where HIV transmission rates are far too high to be explained by reference to sexual behavior alone? After all, it's an empirical matter, not something to be decided on the whim of a bunch of bureaucrats, however well resourced they may be.

Later, after arguing that people's own descriptions of how their sexual orientation has changed were credible, Spitzer concluded that there was no way of determining their validity. In addition to retracting the findings of the study he also apologised to the gay community, particularly to those who underwent the therapy. All credit to Dr Spitzer for making the retraction and for apologising; this is a significant breakthrough in the way science is presented to the public.

The issue of latching on to findings that support prejudices and ignoring those that don't is important when it comes to HIV related policies in high prevalence countries. People's claims that they haven't had sex, that they haven't had unprotected sex or that they haven't had sex with anyone other than their HIV negative partner are often dismissed if the people are found to be HIV positive. But if people claim to be convinced by various HIV 'interventions' of the finger-wagging variety (ABC, Abstain, Be faithful, use a Condom, etc), they are believed. Enormous amounts of money have been spent on interventions of this sort, ostensibly supported by such claims.

Now that mass male circumcision is being aggressively (some might say pathologically) promoted for both adults and children, there is 'research' claiming that men who have been circumcised are less likely to engage in 'unsafe' sex and even that they and their partners find sex more pleasurable. Naturally this research is believed, even though there is no way of testing the validity of people's responses or of judging their responses to more credible than responses that do not support any popular prejudices.

Why is it considered so shameful for a scientist to change their mind, to admit they have made a mistake or to reanalyze something? One might expect that scientists tasked with figuring out how HIV is transmitted and finding ways of reducing transmission would be rewarded for contributing to either or both of these results. But most HIV research concentrates on sexually transmitted HIV, even though non-sexual transmission has been acknowledged since early on in the epidemic. And most interventions concentrate on sexually transmitted HIV, despite there being no clear idea of the relative contribution of sexual and non-sexual modes of infection.

Indeed, the much vaunted circumcision trials do not make it clear how many participants were infected sexually and how many were infected non-sexually, perhaps even as a result of taking part in the trial. This undermines the research itself because circumcision may be even more effective than claimed in reducing sexual transmission. But these matters are not analyzed in the published papers.

Those currently promoting male circumcision also found and published evidence that certain hygiene practices can give higher levels of protection against HIV transmission than circumcision. But there is probably less than one million dollars behind research into penile hygiene, in contrast to the tens of millions behind circumcision research or the hundreds of millions earmarked for circumcision programs. Reducing HIV transmission just doesn't seem to be driving the decisions about which data to give the most attention to.

Perhaps those behind vast circumcision programs are in quite a different position from Dr Spitzer. It's hard to imagine how their funders would react if the researchers said publicly that there is evidence that a lot of harm may result from their programs and that there are far cheaper, more effective and safer ways of reducing HIV transmission. While the notion of 'reparative' therapy is bizarre, it's easy to see why it was embraced by bigots. But what kind of attitudes could lie behind mass male circumcision programs? And how should these attitudes best be addressed before the programs do any more damage?

However, there were 10 men waiting outside the same operating room for circumcisions, which are claimed to cost around $60 (though when you add in the real costs they are about double that). Yet the current circumcision program is free and well resourced because the operation is supposed to protect men from being infected with HIV during penile-vaginal sex.

Each cesarean performed has a good chance of saving both the mother and the child. This is despite the poor health conditions that might result in serious illness or death for both following, perhaps even as a result of, the operation. But it could take 75 or more circumcisions to avert one HIV infection, and that's something of a best case scenario. It appears that women don't come second on the health agenda, after men; they come third, after men and children.

But Alice Nyambai of Homa Bay District AIDS coordinator's office, while approving of the operation for minors, also highlights a need for swabs, surgical spirits, latex gloves and Jik (a brand of bleach). This comment corroborates findings that supplies used in infection control in health facilities in Kenya (and other African countries) are poor. Just how safe are conditions in facilities that are trying to handle thousands of circumcision operations when they are often unable to cope with routine health provision?

Nyambai points out that circumcision in children and infants can be cheaper than for adults, citing a $60 figure for the latter and a $12 figure for the former group (though, as the $60 dollar figure doesn't include all the costs, the $12 figure probably doesn't either). But does the fact that the operation is cheaper make it any more justifiable, under the circumstances? The cost of more vital and cost-effective procedures is far lower, but those costs are frequently not met, with the number of children and infants dying of treatable and preventable illness running into tens of thousands every year.

HIV prevalence in parts of Nyanza province is high among the Luo people, among whom circumcision rates are also low. But the same research that purported to show that circumcision reduces the risk of transmission from females to males also showed that it may not be the lack of circumcision that increases HIV transmission risk, but something else entirely. Which makes one wonder why circumcision enthusiasts were so cavalier about having no idea what mechanism might be involved in the claimed protective effect of circumcision.

Circumcision proponents continue to ignore their own evidence about a cheap, safe and effective strategy for reducing HIV transmission: penile hygiene. Indeed, they continue to withhold some of the data they themselves collected. Instead, plans to circumcise tens of millions of adults, and probably similar numbers of children and infants, are to go ahead This is all costing billions of dollars that would save far more lives if spent on genuine priorities, with all the well-documented risks involved in rolling out such a program. It sounds as if these public health 'experts' are not answerable to the people they claim to be serving.

WHO effectively contracdicted themselves by denying that injectable hormonal contraceptives increased the risk of HIV transmission from HIV positive men to HIV negative women and from HIV positive women to HIV negative men, despite several pieces of research suggesting otherwise. While the WHO may be right, they accepted that the issues involved are far from clear. The effective contradiction stems from categorical advice to continue using Depo Provera and the like while at the same time admitting that they really don't know yet because the appropriate research has not been carried out.

In the absence of clarity, it would be better to advise women that they could face a higher risk of being infected if they are negative and of infecting their partner if they are positive. There are alternatives to Depo, far cheaper alternatives, and some of these, such as condoms, protect against HIV and sexually transmitted diseases as well as preventing pregnancy. Where condoms and other methods are not an option, it seems unlikely that other precautions will be taken.

As for the use of antiretroviral drugs by HIV positive people to reduce transmission, many people in high prevalence countries don't know their HIV status and only about one third of those who are HIV positive are on ARVs. Many of those on ARVs may not even be adhering to their drug regime closely enough to keep their viral load down and others may already have developed resistance, or have been infected with a resistant strain of the virus.

People are calling for further research and greater clarity. Women (and their partners) have a right to the sort of information that WHO are saying is not available. If the information is not available, the use of Depo and similar drugs should be reconsidered, especially injectable Depo. Advising women to continue the practice, but also "to use condoms and other HIV preventive measures), even women thought to be at high risk of infecting others and those at high risk of being infected, is not good enough.

There seems to be a lot of value placed on continuing to sell pharmaceutical products in developing countries, using 'aid' money, of course, regardless of any possible consequences. The use of antiretroviral drugs to prevent transmission of HIV from mothers to their children has been highly successful, as has their use to keep HIV positive people alive for many years. But this should not result in the totally indiscriminate use of drugs in the name of public health.

It is sometimes argued that HIV positive women who become pregnant risk their child's health as well as their own. But HIV transmission will not be eliminated by a blanket birth control policy, which is an entirely separate matter. Women are entitled to adequate information about whether to use birth control, as well as what method of birth control to use. The threat of HIV infection for them, their partner or their children, should not be used to promote a Western population control agenda, particularly when one of the most aggressively marketed methods, injectable Depo Provera, has been associated with an increased risk of HIV infection.

So they will be welcoming a piece of self-serving research purporting to show that the industry has been right all along, that it is OK to continue spending more on one disease that grabs a lot of attention than on all the others put together, which don't grab so many headlines. Health facilities are in abysmal condition, with low levels of staff, many of whom are badly trained; there are chronic shortages of equipment and supplies, etc. There is a lot of evidence that health facilities are quite dangerous places to go to when you are sick, as you may leave with something worse than you had when you arrived.

But this research didn't seem to look into such mundane matters. How often do hospital transmitted HIV infections ever grab headlines, anyhow? A significant proportion of HIV infections might be averted if conditions in health facilities were improved. This would also cut the number of infections with various other diseases that are most efficiently transmitted in modern healthcare settings, especially where safety and infection control have been almost entirely ignored.

The article seems to concentrate on treatment and care, with very little mention of prevention of HIV or other diseases. But the bulk of HIV money goes into drugs and other technologies. That's one of the things that makes it such an expensive disease. Not that producing the drugs is expensive, just that pharmaceutical and other companies make inordinately high profits from them. The fact that the majority of people with HIV live in poor countries is not a problem now that intensive lobbying has ensured that what may look like foreign aid is no more than a de facto subsidy for the pharmaceutical and other industries.

I haven't got access to the research on which this article was based but even the language used by the lead author is very cautious. It is unclear if the health facilities providing HIV services were already superior to those not providing the services, used for comparison. It is concluded that "the experience in Rwanda adds to a growing body of evidence from several countries that AIDS-related funding is not adversely affecting non-AIDS services". But some AIDS related programs such as mass male circumcision, which will provide little or no benefit, may even result in HIV infections that wouldn't otherwise have occurred.

Well done to the researchers for finding new ways of coming to the conclusion the HIV industry wants, this will ensure future funding. But how does this research contribute to a reduction in HIV transmission, or even transmission of other diseases? It's clear that billions can be made available when the right interests are involved, so why do people with a difficult to transmit disease receive lots of money if they are infected, but next to none to protect them from being infected in the first place? If the fight against other diseases is not undermined by HIV funding, even if the fight is strengthened, how much more could be done if funding were to be distributed in a reasonable and balanced way?